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Vulnerability and Self-Medication
39th Annual Addictions Institute

June 2007

The Addictions Committee of NASW-NYC held the 39th Annual Addictions Institute on March 15th at Fordham University. The workshops and presentations centered on the theme “From Prevention to Motivation: The Evolving Role of Social Work Practice in the Addictions.”

The keynote speaker, Edward Khantzian, M.D., addressed the topic “Substance Use Disorders: Why Are Some of Us More Vulnerable than Others?”

Dr. Khantzian, a psychoanalyst and Clinical Professor of Psychiatry, Harvard Medical School, and a founding member of the Department of Psychiatry at The Cambridge Hospital, is the author of Treating Addiction as a Human Process, 1999 and Addiction and the Vulnerable Self, 1990.

Lifelong Human Challenges

As humans, said Dr. Khantzian, we face lifelong challenges in regulating our emotions and in handling self-esteem issues and relationships. Addictive drugs help to alleviate the pain and distress brought on by such challenges. Certain individuals who are susceptible to psychiatric illness and behavioral disorders suffer in the extreme with self-regulatory difficulties. Dr. Khantzian said, “Individuals self-medicate with addictive drugs, because in the short term, such drugs relieve or make more tolerable their psychiatric and psychological distress.”

Specific Drugs Deal with Certain Feeling States

For individuals whose difficulty in handling certain feelings have lead them to distress, certain drugs bring relief. For example, opiates counter agitation and feelings of aggression by helping users to feel calm, mellow, or normal. Stimulants counteract feelings of low energy, feelings of weakness, and feelings of being unloved. Opiates calm individuals who are hyper-energized. Alcohol in high doses drowns out negative and unwelcome feelings. In low doses, alcohol allows feelings of closeness and warmth. Dr. Khantzian said that people who are “too tightly wrapped and cannot get to those parts of themselves that are warm and fuzzy” may rely on alcohol to release certain feelings, while opiates calm those who are “not wrapped tightly enough” and have difficulty containing their emotions.

Self Regulation

According to Dr. Khantzian, individuals experience emotional and psychological pain when they encounter great difficulties in regulating their emotions, self-esteem, relationships, and behavior. He said that a main feature of psychiatric illness is difficulty in self-regulation. Individuals discover that in the short term substances relieve, or help control, emotional and behavioral conditions associated with psychiatric illness.

Schizophrenia Symptoms Increase Substance Use Vulnerability

Those diagnosed with schizophrenia, Dr. Khantzian said, suffer daily from the confusing, evasive and elusive symptoms of the illness. These so-called negative symptoms include apathy, anhedonia (inability to experience pleasure in activities that used to be pleasurable), flattened affect, and attention deficits. Various studies have shown that stimulants such as nicotine and cocaine help with the “inability to connect and with de-energized states.” Alcohol in lower doses helps with symptoms of apathy and anhedonia, while in higher doses alcohol helps block out auditory hallucinations.

PTSD and Substance Use

Dr. Khantzian listed the symptoms of PTSD (post-traumatic stress disorder) as detachment, decreased interest in important activities, and numbing. In addition, re-experiencing trauma in dreams and other situations is common. Self-esteem is disrupted with feelings of shame and guilt, and disruptions in self-care may occur. For such sufferers, certain doses of alcohol may drown out unwelcome feelings while other doses may counteract numbing. Stimulants may be taken to relieve the apathy, social withdrawal, and anhedonia of PTSD. Opiates help to counteract feelings of rage often experienced by war veterans.

ADHD, A New Developmental Disorder

Describing ADHD (attention deficit hyperactivity disorder) as a “new developmental disorder”, Dr. Khantzian cited a study that found that 25-50% of adolescents with substance use disorders are likely to be diagnosed with ADHD. ADHD sufferers experience difficulty in regulating their emotions, self-esteem, and relationships. They commonly use drugs such as marijuana and alcohol, which have both a stimulating and a sedating effect, depending on doses.

Dr. Khantzian called nicotine a “renaissance drug” because it fills different needs for different people. Users find that it improves concentration, relieves anxiety and depression, counteracts anger, and decreases hunger. In a 2005 study that he cited, nicotine was found to fill such needs for adolescents who have difficulties in concentration, who experience difficulty with their emotions, who find social situations to be difficult, and who are obsessed with their weight.

How to Understand Substance Use Disorders

To help those with addictions, Dr. Khantzian said, it is important to understand how substance use relieves emotional and psychological suffering. It is helpful to ask substance users, “What does the drug do for you?”